Medical Necessity Review
A Medical Necessity Review determines the medical necessity and
appropriateness of treatment rendered in health, auto or worker's compensation
cases. A review can be conducted prospectively, concurrently or retrospectively,
and can be useful in making claim decisions involving coverage, causality and/
or need for treatment.
Prospective and concurrent reviews are done by UR certified R.N.s who review
proposed treatment for medical appropriateness, necessity and eligibility under
the plan. Requests for treatment authorization can come from physicians or plan
participants. Treatment requests are reviewed according to nationally accepted
criteria to ensure appropriate level of care and frequency, and according to
plan guidelines for coverage eligibility. If illnesses or injuries are serious,
case management assistance may be initiated.
- 100 percent HIPAA compliance
- 20 years of Experience
- Ability to handle all states
- URAC compliant services
- RNs licensed and UR certified
- Medical Directors in appropriate specialties
Retrospectively, our R.N.s can review documented medical treatment to
determine if the requested or rendered services are covered according to the
terms of the benefit plan or policy, or if the treatment is related to the
covered accident, illness or injury. This review can result in recommendations
as to more appropriate and cost effective alternative treatment, or the need for
specific case management intervention.
Referrals for Medical Necessity Review are acted upon promptly, often on the
same day, and are completed within one week, provided all of the necessary
medical documentation is made available.